Pharmacy Fall Prevention Policy

Mercy Health Center of Oklahoma City, OK, uses this pharmacy fall prevention policy as part of its successful falls prevention program. The policy is reprinted with permission from Burl Beasley, RPh, MPH, medication safety coordinator for the health center.

Pharmacy Fall Prevention Strategy

Purpose: To provide an ongoing service for the review and monitoring of medications or hospitalized patients as related to risk for fall. This is a requirement of the Joint Commission of Oakbrook Terrace, IL, patient safety goal to reduce risk of harm resulting from falls. The Medication Fall Scale will be implemented to meet this requirement and will be reviewed on a quarterly basis.

Background: Falls are among the most common serious problems in elderly persons. Falls account for > 5% of hospital visits and > 10% of emergency department visits. Falls result from an interaction of multiple intrinsic and extrinsic risk factors. Intrinsic factors include: lower extremity weakness, poor grip strength, balance disorder, visual and cognitive impairment. Extrinsic factors include: polypharmacy (> 4 medications) and environmental factors. The Medication Fall Score was developed using multiple resources and references to summarize patient medications into a single numeric value. Based on this value, the Pharmacy Department will review patient medication records and make recommendations per policy. By implementing this policy the goal is to reduce falls as related to medications, thereby improving quality of care.


  1. Medication Fall Risk Scale will be administered by a team of trained clinical pharmacists.
  2. The team will review the Medication Fall Risk Scale Report on a daily basis.
  3. Patients that score 6 points or greater will be further evaluated for medication review.
  4. The assessment team (clinical pharmacists) will use available references to review and recommend modifications to medication regimens.
  5. The assessment team will consider multifactorial etiologies of falls, and medication adjustment will not be used as a sole intervention for fall prevention.
  6. Recommendations will be made in writing and placed in the pink communication record of the patient's chart for physician review.
  7. Documentation will take place in the Meditech computer system by reviewing pharmacist for each patient reviewed under the Patient Care Notes section.
  8. On Saturday and Sunday, the clinical pharmacist for each area will be responsible for monitoring the Medication Fall Risk Scale and completing the duties of the specialized team. These pharmacists will gather and maintain information for review on Monday.